NCLEX-PN
NCLEX Neurological Disorders Questions
Extract:
Question 1 of 5
After receiving report, the nurse working on the step-down neurological unit begins care for four clients. Prioritize the order in which the nurse should assess the four clients.
Correct Answer: C,A,B,D
Rationale: The 24-year-old who had been unconscious at the scene of an MVA and is being admitted from the ED for observation. The nurse should assess the newly admitted client first to determine whether there are changes in level of consciousness and any early signs of increased ICP. The 78-year-old who underwent evacuation of a chronic subdural hematoma 24 hours earlier and is recovering. This client should be assessed next because the client is postoperative day 1, but stable. The 30-year-old who was diagnosed with viral meningitis 2 days earlier and wants to talk with the HCP. This client has a self-limiting condition and likely wants to be discharged; thus, he or she should be assessed third. The 40-year-old with Guillain-Barré who is currently receiving a third bedside plasmapheresis treatment being administered by another nurse. This client can be assessed last because another nurse is in the room with the client administering the plasmapheresis treatment.
Question 2 of 5
The client who just had a three (3)-minute seizure has no apparent injuries and is oriented to name, place, and time but is very lethargic and just wants to sleep. Which intervention should the nurse implement?
Correct Answer: C
Rationale: Post-seizure, the client is in a postictal phase with lethargy. Turning to the side (
C) prevents aspiration and allows safe rest. Neurological assessment (
A) can wait until the client is less lethargic, frequent awakening (
B) is unnecessary if oriented, and interviewing (
D) is not urgent.
Question 3 of 5
The client has been newly diagnosed with epilepsy. Which discharge instructions should be taught to the client? Select all that apply.
Correct Answer: A,C,D,E
Rationale: Recording seizures (
A) helps track treatment efficacy, avoiding OTC medications (
C) prevents interactions, regular serum levels (
D) ensure therapeutic dosing, and not driving alone (E) ensures safety. Tub baths (
B) pose a drowning risk and are not advised.
Question 4 of 5
After receiving report, the nurse working on the step-down neurological unit begins care for four clients. Prioritize the order in which the nurse should assess the four clients.
Order the Items
Source Container
Correct Answer: C,A,B,D
Rationale: The 24-year-old who had been unconscious at the scene of an MVA and is being admitted from the ED for observation. The nurse should assess the newly admitted client first to determine whether there are changes in level of consciousness and any early signs of increased ICP. The 78-year-old who underwent evacuation of a chronic subdural hematoma 24 hours earlier and is recovering. This client should be assessed next because the client is postoperative day 1, but stable. The 30-year-old who was diagnosed with viral meningitis 2 days earlier and wants to talk with the HCP. This client has a self-limiting condition and likely wants to be discharged; thus, he or she should be assessed third. The 40-year-old with Guillain-Barré who is currently receiving a third bedside plasmapheresis treatment being administered by another nurse. This client can be assessed last because another nurse is in the room with the client administering the plasmapheresis treatment.
Question 5 of 5
The client is in the terminal stage of ALS. Which intervention should the nurse implement?
Correct Answer: A
Rationale: In terminal ALS, passive ROM every 2 hours (
A) prevents contractures and maintains comfort. Negative nitrogen balance (
B) is undesirable, low-protein diets (
C) are not indicated, and coughing/deep breathing (
D) may be infeasible.